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When Your Patient Is Too Busy to Take Meds

Two experts describe how they would encourage adherence in an AIDS patient already overburdened with work and family responsibilities.

A 31-year-old woman was diagnosed with HIV infection in January 2002, when she was pregnant with her first child. Her initial CD4 count was 350 cells/mm³, and her viral load was 15,000 copies/mL. She was started on AZT/3TC + nevirapine but was switched to AZT/3TC + nelfinavir after developing fever, rash, and hepatitis. After her baby was born HIV-negative, she continued on this regimen for several years. However, the father of the child left her soon after the delivery, and she was forced to work two jobs as a medical assistant while asking her extended family to help care for the child. She frequently missed follow-up appointments and acknowledged that she often stopped treatment when life became too chaotic or she didn’t remember to refill her medications. A resistance test in 2006 — at which time her CD4 count was 440 cells/mm³ and her viral load was 8000 copies/mL — showed M184V (resistance to 3TC and FTC), D30N (resistance to nelfinavir), and no NNRTI mutations. She was then lost to follow-up for 2 years, returning only when she sought care for dermatomal herpes zoster. She was treated with famciclovir uneventfully; however, she stated that she had not taken any antiretrovirals for more than a year and could not imagine taking a twice-daily regimen or one with a lot of pills, given her work and life stresses. Her CD4 count was now 140 cells/mm³, and her viral load was 33,000 copies/mL.

What strategies would you use to improve this patient’s adherence? Which would you start first — Pneumocystis jirovecii pneumonia (PCP) prophylaxis or antiretroviral therapy (ART)? What specific ART regimen would you choose?

Response 1

— Lisa Capaldini, MD, MPH

My first priority would be to make sure this patient is confident working with me and that she understands the logistics of my practice. Studies have shown that one of the most robust predictors of treatment adherence in HIV-infected women is their perception of their provider as knowledgeable, trustworthy, and showing interest in them. Other studies have shown that the most specific predictor of quality of life in women with HIV is the presence or absence of depression, not of HIV surrogate markers. I would want this patient to leave our first visit or two not with an ART prescription but with the sense that we have a relationship she can trust and build on over time.

This patient has many options for her next regimen; the key is to find the best fit for her. To do this, I would focus on the priorities she’s already identified (once-daily dosing and low pill count) and also gather some additional information:

• What happened with her prior regimens? Was her adherence problem simply an issue of remembering to take her meds? Did she have side effects? Were the problems logistical (e.g., affording co-payments, getting to the pharmacy, getting to her appointments), or were they psychological? Depression and post-traumatic stress disorder are extremely common in women with HIV disease.
  
• What are her reproductive/contraception plans? Is she sexually active? Is she on estrogen-based birth control? Does she plan to get pregnant?
  
• What is her day-to-day schedule like? Does she prefer to take her antiretrovirals with or without food?
  
• Most important, what are her attitudes about having HIV — and her beliefs and expectations about being on ART?
  

Once we’ve worked through these questions, I would start discussing the importance of treatment adherence and open communication. In particular, I would emphasize that if the next regimen is not the right fit, we can modify it, but she must continue taking the regimen as prescribed until she has checked in with me and we’ve had a chance to discuss whatever problems have arisen. The metaphor that many patients can relate to is leasing a car: When you lease a car, you’re not committed to keeping it year after year, but you are committed to taking good care of it during the lease. This approach requires both accountability on the patient’s part and availability and flexibility on the clinician’s part.

In terms of medications, I would start PCP prophylaxis first, explaining to the patient that we’ll be able to stop it once her CD4 count is 200 cells/mm³. For antiretrovirals, I would try to get a feel for just how important once-daily dosing and low pill count are. If they are deal breakers, I would go with tenofovir + ddI + ritonavir-boosted atazanivir, recognizing that many other drugs could also be dosed once daily (e.g., abacavir, maraviroc, boosted fosamprenavir, boosted darunavir, and possibly even raltegravir, based on recent findings about its pharmacokinetic profile).

Response 2

— Robert Gross, MD, MSCE

This scenario is familiar to most HIV care providers in the U.S. because of the high proportion of patients already saddled with social and medical difficulties, such as poverty, unstable family lives, substance abuse, and mental illness. The care of these patients is often fragmented, occurring only during symptomatic episodes.

Whatever recommendations we make for this particular patient are irrelevant if she does not adhere to therapy, so I would spend substantial time on this issue, taking care to be nonjudgmental and encouraging. Adherence is a dynamic phenomenon, such that an individual who was previously nonadherent may become adherent (and, unfortunately, vice versa).

I would begin by focusing on two points: (1) goals and motivations and (2) barriers to adherence. To understand her motivation for treatment, I would first ask her why she presented for the current visit. She has already identified dosing frequency as a barrier to adherence, and I would encourage her to list others. I would screen her for depression and also ask her about substance use, her ability to pay for medications, and any prior adverse events. I would then work with her to begin mitigating the barriers over the next two or three visits.

At the first visit, I would recommend that she begin PCP prophylaxis with trimethoprim/sulfamethoxazole, either three times a week or daily, whichever she prefers. I would construct a daily timeline and link the pill taking with a routine (e.g., toothbrushing). I would see her monthly, ask her about adherence, and encourage any medication use. At the same time, I would explain concretely that ideal adherence should be the target.

I would encourage her to begin ART within 3 months of the first visit, given her low CD4-cell count. Although she prefers a once-daily regimen, her resistance pattern makes all once-daily choices suboptimal. Therefore, I would work with her to fit a twice-daily regimen into her day and would offer her tenofovir (300 mg once daily) + AZT (300 mg twice daily) + a boosted PI. The PI choices would include atazanavir, darunavir, fosamprenavir, and lopinavir, depending on the adverse effects she might tolerate, her preference for taking only a single drug a second time a day (i.e., AZT), and her threshold for "a lot of pills." I would again link the pill taking to routines and would offer to set her cell phone alarm as a reminder. I would schedule follow-up visits at weeks 2, 4, and 12 and ask her each time in a nonjudgmental way about ongoing adherence; I would also identify any new or unresolved barriers and encourage her based on her self-described motivation.

Tell us what you would do

How would you manage this patient? Submit your comments below.

Dr. Capaldini is Assistant Clinical Professor of Medicine, University of California San Francisco. She serves on the speaker’s bureau for Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Merck, Pfizer, and Roche.

Dr. Gross is Assistant Professor of Medicine and Epidemiology, Division of Infectious Diseases, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine. He has received research support from Abbott Laboratories and Gilead Sciences.

Published in Journal Watch HIV/AIDS Clinical Care May 18, 2009

Reader Remarks:

Read all Reader Remarks on this article

• Depression and Once-Daily Dose
  Alexandre Naime Barbosa, Fac Medicina Unesp, 19 May 2009 8:09 AM EST
  I think that the most important point is to prescribe a easy combination, like Once-Daily Dose, associated to a good... [more]
• Patients too burdened to take ARVs
  OLAYINKA. A OLASODE, OBAFEMI AWOLOWO UNIVERSITY, ILE IFE, 14 Jun 2009 5:40 AM EST
  We have the same scenario in our practice as well as some patients stopping medications on religious convictions that they... [more]